Friday, 20 June 2014

Guest post: 'Schizophrenia then and now'

The cuckoo's nests have closed. What else has changed in mental health?

The theme
of this year’s World
Mental Health Day on 10th October is Living
with Schizophrenia. For those of us of a certain age, and with a historical
bent, it’s also an opportunity to compare services now with those provided when we started out in
the 1960s. Recently we’ve had the privilege of editing the diaries and
letters of a young man, David, a patient in the mental health system five
decades ago. The resulting book offers, we think,
a window into the social attitudes of the time and the way mental health
problems were treated.

David progressed
in 1958 from child guidance clinic, to adolescent unit, to revolving door
hospital admissions (five as an inpatient and two as a day patient), and three
failed attempts at rehabilitation. He spent nearly six years as an inpatient
although he was never placed in a long-stay hospital. Fortunately, he did not
receive narcotherapy,
insulin coma
therapy, or a leucotomy,
like some of his fellow patients. He eventually opted for ECT, perhaps
a difficult choice, but the offer was then withdrawn. When he committed suicide
at the age of 27, he was working and living independently, and in a rational
frame of mind. Something that hasn’t changed is the high rate of
suicide among people with a label of schizophrenia.

The NHS in
the 1960s was a service without geographical barriers. David received help
wherever he happened to be living or was sent. Nowadays, moving home across the
street could mean transferring to a new set of workers in a different CMHT. We
know of one young man, recently readmitted to hospital during a psychotic
episode, who was told to go back home by bus to fetch his medication (which he
was quite incapable of doing). Medication had to be paid for by his GP, not the
hospital!

Financial
accounting in the 1960s followed a corner shop mentality. David was paid by the
hour for work he carried out at OT, but when he worked outside the hospital, he
had to return a large proportion of his earnings for his upkeep. The message he
continually received was ‘get back to work’ and some of his psychiatrists
adopted the attitude that he was both mad and lazy. Attempts at industrial
rehabilitation in simulated real-life conditions always failed, and there
appeared to be no assessment of his psychological needs. In fact, there was an
absence of any psychological intervention apart from cognitive assessment.

In
the early 1960s, nurses were forbidden access to his case notes and they had no
designated therapeutic role. We interviewed a man who had nursed David and
remembered him well. Apparently, nurses became close to patients through daily
contact, but speaking to relatives about family matters would have been seen as
treading on medical authority. This proscription seems particularly absurd
given that we could find no evidence that David ever received any counselling
and interviews with doctors were solely concerned with privileges and
medication.

Psychiatric
textbooks of the period painted schizophrenia as an incurable progressive
deterioration of the personality. Medication was given to merely ameliorate its
effects. David received almost every new drug as it appeared on the market,
becoming seriously addicted to Mandrax. He firmly
believed that medication was destroying his memory and intelligence, and there
are some who would
argue that he may not have been far off the mark. One reason for writing
his diaries was to have a record of what happened to him.

With
respect to viewing schizophrenia as amenable to therapy, there has been a
profound revision of the dogma of intractability and inevitable decline. These days
there may be greater optimism about new approaches to therapy. However, whether
there is a sufficient
number of skilled professionals and other resources to make this presently
available is a different matter. As in the 1960s, the first line of treatment
is still medication.

According
to surveys
the stigma of ‘severe mental illness’ has changed little. David’s family always
regarded him as rational, if occasionally a bit ‘potty’ or ‘bonkers.’ David’s
preferred terms of abuse, applied as much to himself as to his doctors,
included ‘psychotic’, ‘paranoid’ and ‘neurotic.’ Illustrating the stigma
attaching to these labels, when David attempted to explain to a potential
employer that he had only ‘mild schizophrenia’, this was met with fury by his
Mental Welfare Officer who said that he had deliberately sabotaged his chances.
Shortly before his suicide, David talked of being tormented by local youths,
and he was dismayed to discover at work that everyone knew he was living in a
half-way house in the grounds of a mental hospital.

So
what has happened to the system of David’s time? The closure of the large
mental hospitals and the introduction of community care is the most obvious
change. Some of the hospitals he attended remain open. One is now a housing
estate. Of two rehabilitation settings, one is a private school, the other a
Management Training Centre. Hospital beds have been reduced from around 150,000
in the 1950s to around 20,000 today, leading one to doubt that there is a
sufficient number for temporary refuge.

Acute
wards in David’s hospital contained people with a toxic mix of problems, as
happens now, although it is unlikely that present day wards would include the
dementing elderly and youths convicted of GBH. On the non-acute wards he was
able to enjoy a leisurely, if rather pointless, existence of evenings in the
pub, cricket, reading library books, dances at OT, and conversations with
nurses and fellow patients about current affairs. To live independently today,
in loosely supervised accommodation where residents do not talk to each other,
is probably far more demoralising. Real involvement in the community was rare. David
eventually achieved something in this respect but at the cost of great stress
to himself. There are now ‘survivor’ movements that offer alternative identities
and a political voice and this represents one of the most profound shifts
since David’s time.

Perhaps
of most concern though are the present cuts to mental health budgets and
welfare benefits. There are more than a few echos of 1960s in the emphasis on
paid work and the view that self-management as the solution to everything. In this respect it's unfortunately a case of plus ça change Mr Duncan-Smith.

2 comments:

Absolutely fascinating Richard and Michael. Thanks. It's strange to think how, for all the flaws of the old system, some potentially valuable things have been lost. Depressing too to think that a sort of 'pull your socks up and get to work' view is gaining so much traction again. Plus ca change indeed!

Am one of the happiest Father on earth,My son onces suffered from the problem Schizophrenia which made him not to go to school,and that was killing his educational carrier.he can not control his emotions,always having nosies on his head affect how he thinks, feels and acts,he has taken different medication,but no cure,then i got the contact of a doctor who helped my son. he gave me the medication which my son used, he took the medication for two weeks,and that was the end of the problem.he can now control his emotions,no more severely distorted self-image and feeling worthless acts, his thinking is normal and no more voices on his head any more.any one that need his medication should contact the Doctor on benardleo13@gmail.com

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The Salomons Centre for Applied Psychology in Tunbridge Wells, England. We are part of the Canterbury Christ church University Department of Psychology, Politics and Sociology. We run training courses in Clinical Psychology and CBT and also practice improvement programmes for child and adolescent mental health services. On this site staff and trainees in the Department write about a wide range of issues related to applied psychology, psychological therapies, policy and health service development.